“There are grounds for optimism that we are getting
better at preventing vascular cognitive impairment,”
Greenberg said. “We really don’t have effective prevention
treatments for Alzheimer’s, but for vascular cognitive
impairment, we probably do.” It may be that treating heart
disease risk factors — lowering blood pressure, preventing
or treating diabetes, reducing cholesterol, eating a heart-healthy diet and being physically active — are lowering
the risk for VCI as well. “There’s real reason to think those
will work. Until we have better treatments, they’re the most

Risk factors

Aging is the primary risk factor for VCI, and beyond that,
what puts someone at risk of stroke increases their risk of
VCI. High blood pressure is a major risk factor, and diabetes
and high cholesterol also. Although these conditions are
present when VCI shows up, their damaging affects begin
in middle age (45-55). “Of course, we want people to be
heart-healthy and brain-healthy through their whole lives,
but certainly midlife is a very promising time to change your
lifestyle to lower the risk for cognitive impairment 10 or 20
years later,” Greenberg said.

Prevalence

It may be difficult to distinguish VCI from Alzheimer’s
disease, but it is not difficult to see that dementia in general
is a huge problem: As many as half of all 85-year-olds have
some form of dementia. And maybe not just one form:
“There is good reason to think that the mixed form may be
the more common form of dementia,” Greenberg said. “No
matter how you look at it, these are very high numbers. If
we could remove the vascular side of dementia, we could

Some good news

Even though dementia is increasing because the
population is aging, its prevalence in any particular age
group is coming down. In a recent article in the New
England Journal of Medicine, the authors found that risk
ratios for dementia had declined 44 percent in the past four
decades — from 3. 6 per 100 in the 1970s to 2.0 per 100
in the 2010s. (This only held true for people with at least a
high school diploma.) Interestingly, “the prevalence of most
vascular risk factors (except obesity and diabetes) and the
risk of dementia associated with stroke, atrial fibrillation
or heart failure have decreased over time, but none of these
trends completely explain the decrease in the incidence of
dementia,” the authors said.

“We know that even small decreases will have enormouspublic health impact as the population ages,” Greenbergsaid. “If we can delay the average start of dementia by evena few years, that’s a huge amount of the burden being liftedfrom the population.”

Caregivers

The impact of dementia on families can be enormous,
whether the patient is cared for at home, in a nursing home
or a memory-care facility. Whichever course is taken, there is
a heavy financial impact, be that a loss of earnings for time
away from work or the cost of residential care. Generally, the
patient prefers to stay at home, but that may not be possible
as the condition progresses. A person with dementia may feel
anxious, upset or agitated in certain places or when focused
on specific details; as a result, they become restless and need
to pace or move around. “Agitation is often the strongest
predictor of a family deciding that their loved one needs to be
moved to some type of facility for care,” Greenberg said.

The degenerative process also creates an emotional
burden for the family, as their loved one deteriorates. “One
of the things that makes all forms of stroke so burdensome to
individuals and to society is that people can live for years in
an impaired state, which continues to add to the emotional and
financial burden placed on some caregivers,” Greenberg said.

“I don’t think there are any perfect solutions,” he said.
“Anyone who has spent time in a long-term care facility
knows that it’s unfortunately very easy to have bad situations,
patients become unhappy and agitated. Dementia is the
challenge and burden for our society, to try to prevent and
effectively treat all forms of it. Right now, the vascular
component may be the most preventable form, which is to me
the unrecognized victory that we should be celebrating — at
least it’s a partial victory.”

In 2011 the Obama administration began
implementing the National Alzheimer’s Project Act
to fund research into Alzheimer’s disease-related
dementia. VCI was specifically listed for funding, and
funding initiatives have come from the National Institute
on Aging and the National Institute on Neurological
Disorders and Stroke.

“To me this reflects the real matching of resources to
the public health magnitude of the problem,” Greenberg
said. “I think NIH has recognized the scale of vascular
cognitive impairment and is apportioning research
funds to the scale of the problem. I am confident that
research dollars will lead to advances in our ability to
prevent and treat vascular cognitive impairment.”